Challenges Facing Employers in the Treatment of Depression

OBJECTIVE
To review the challenges of treating depression in the workplace in the environment of increased health care costs.


SUMMARY
The cost of health care is on the rise, and employers and employees are at odds over who will share the burden of these costs. The focus of cost containment has been to minimize drug cost; however, employers need to be aware of indirect costs of medical illness. Due to its prevalence and rate of undertreatment, depression is one of the main disease states that employers should target in their disease management efforts.


CONCLUSION
In order to treat depression appropriately, we must consider the social stigma, treatment barriers, and health care structure that exist to treat depression. Additional outcomes data is needed to demonstrate to employers, the largest purchasers of health care, the benefit of managing depression in the workplace.


■ ■ Health Care and Employers
Employers are keenly aware of this rise in health care expenditure s because they are one of the major payers for health care. In the face of double-digit inflation, employers are transferring larger fractions of the cost, especially medication costs, to their employees. This t rend can unfortunately result in increased costs in other are a s , thus only shifting the cost.
The Institute of Medicine has re p o rted that, in the way we deliver health care, there are areas for impro v e m e n t . 3 For example, we do not offer preventive care for 50% of Americans, and the care that we do deliver is fragmented. 4 Employers must recognize the cost savings of providing preventive care versus the cost of untreated illnesses.
Medical errors, the rise in incidence and prevalence of cert a i n diseases, and new technologies for detection and treatment of illnesses for our aging population are also sources of rising cost to both the health care provider and patients alike. In addition to quality care, patients expect that health care providers work in a c o o rdinated fashion to optimize treatment. Unfort u n a t e l y, this does not occur in many instances.
Despite these difficulties and the rising cost of pharm a c e u t i c a l s , t h e re have been significant improvements in the treatment of many major disease states. Medications, in general, have been quite effective in improving the lives of patients with HIV, cancer, and heart disease. 5 For example, between 1980 and 2000, there has been a one-third decrease in the number of deaths per 100,000 population due to heart disease. The question remains as to whether we are able to achieve reductions in morbidity and acute care costs while increasing productivity and quality of life for patients with mental illnesses such as depression.

■■ Depression
One area in which there is potential room for improvement in cost savings to the employer and benefit to the employee is in the t reatment of depression. Depression is one of the most debilitating diseases that have significant effects on patients, family members, and society. Major depression is currently the leading cause of disability worldwide. 6  SUMMARY: The cost of health care is on the rise, and employers and employees are at odds over who will share the burden of these costs. The focus of cost containment has been to minimize drug cost; however, employers need to be aware of indirect costs of medical illness. Due to its prevalence and rate of undertreatment, depression is one of the main disease states that employers should target in their disease management efforts.
CONCLUSION: In order to treat depression appropriately, we must consider the social stigma, treatment barriers, and health care structure that exist to treat depression. Additional outcomes data is needed to demonstrate to employers, the largest purchasers of health care, the benefit of managing depression in the workplace. income, and suicide. 7 A c c o rding to the National Institute of Mental Health, depression affects 18.8 million Americans, or about 10% of the adult population. 8 The lifetime prevalence in the community sample is 16.2% according to the recent National Comorbidity Survey-Replication (NCS-R). 9

Treatment Options
The treatment of depression has changed significantly from the days of Freudian philosophy when mental illnesses were f requently attributed to nonbiological etiologies. 1 0 Older tre a t m e n t s such as insulin and electroconvulsive therapy were commonly used to treat many mental health disord e r s . 1 0 When the neuroc h e m i c a l basis for depression was discovered, drugs such as monoamine oxidase inhibitors and tricyclic antidepressants were c o n s i d e red the gold standard for the treatment of depre s s i o n . 1 1 U n f o rt u n a t e l y, these agents were associated with problems such as c a rdiac arrhythmias, significant sedation, anticholinergic eff e c t s , and orthostatic hypotension.
In the 1980s, the first drug in a class of selective sero t o n i n reuptake inhibitors (SSRI) was discovered and, again, dramatically changed the way we treated depression. These drugs not only t reated the depressive symptoms but also were significantly better tolerated by patients. Of course, SSRIs are not without their own side effects, and patients must still be monitored for symptoms such as sedation, agitation, headache, gastrointestinal pro b l e m s , and sexual dysfunction. 1 1 Challenges to Treatment Treatment of depression, however, is not solely dependent upon choosing the right medication for a patient. There are many challenges that exist in the treatment of mental illnesses, including d e p ression. Patients and providers alike must overcome the stigma of the disease and the antiquated views that suggest that depre s s i o n is simply a state of mind. Beyond the difficulty of identifying patients with depression, getting the patient to agree to re c e i v e t reatment is a significant hurdle in itself. In addition, it is diff i c u l t to convince patients to continue with their treatment when i m p rovement is not usually seen until after 4 to 6 weeks of therapy. Patients are often faced with short -t e rm side effects without much i m p rovement in their mood, thus resulting in discontinuation of the medication. F u rt h e r, recent re s e a rch indicates that the best method for t reating depression is a combination of psychotherapy and m e d i c a t i o n s . 1 2 , 1 3 P roviding patients with access to an adequate trial of psychotherapy is perhaps even more challenging than a c q u i r i n g medications and, again, impedes the process of pro v i d i n g o p t i m a l therapy for the disease. Finally, we have little outcome data pertaining to treatment options for depression. More re s e a rch is still needed to determine the impact of depression on absenteeism, p ro d u c t i v i t y, and the overall bottom line for payers. Employers are not willing to spend more dollars without reasonable expectation of an adequate re t u rn on their investment. Payers would benefit f rom data that demonstrate the value of spending more money on t reatment of depression and how to spend the money in ways that make both clinical and economic sense.

■ ■ Conclusion
Despite these gaps and barriers, we have opportunities, in terms of access, quality, and cost, to take advantage of newly emerg i n g m o d e l s of care to improve depre s s i o n t reatment. Emerging e v i d e n c e has shown that quality care can prevent relapse and integrated care models can improve outcomes for patients and health care systems. Minimizing costs while improving the health and quality of life for employees remains a significant challenge for most employers. We need to have more employers who are willing to look at the problem globally instead of simply shifting cost to their employees.